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Adverse Health Events Key Messages – Year 11
Feb. 26, 2015
Overall messages
Minnesota’s nation leading adverse health event reporting system tracked four new events this year
in an effort to further improve patient safety. The addition of four new events demonstrates
Minnesota’s commitment to continuous improvement.
The adverse events reporting system provides a strong system for learning and improvement. In the
15 years that MHA has been spearheading patient safety efforts, hospitals have shown remarkable
commitment to improving patient safety.
 As trends are identified in the data, aggregate information about the event, including
findings from the root cause analyses and hospital action plans, are communicated to
hospitals in the form of safety alerts and/or are incorporated into best practice
recommendations.
 Over 90 percent of Minnesota hospitals participate in many of the association’s eight
statewide initiatives aimed at reducing patient falls, pressure ulcers, retained objects,
wrong site procedures, adverse drug events, readmissions, healthcare-acquired
infections, and improving culture.
 115 hospitals committed to achieving bold aims to improve safety through the
Partnership for Patients campaign, with the goal of achieving a 40 percent decrease in
healthcare-acquired conditions and a 20 percent decrease in readmission.
o Between 2012 and 2014, Minnesota’s hospitals achieved a 37 percent reduction
in harm, preventing more than 13,000 patients form being harmed and saved
more than $93 million.
A strong safety culture within our hospitals/health systems is the foundation of patient safety and
quality improvement efforts.
 Hospital staff are encouraged to report any potentially unsafe situation, and should feel
comfortable doing so.
The adverse events described in this report are extremely rare.
 In the 2013-14 reporting period, Minnesota hospitals provided care for roughly 2.6 million
patient days. Patient days represent the cumulative number of days patients received care. The
complexity of these patients is increasing—people are living longer and with more chronic
health conditions.
Updated 2/20/15
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Pressure ulcers (pg. 18)
In recent years, hospitals have made progress in preventing pressure ulcers.
 The majority of patients developing serious pressure ulcers are very ill with complex medical
conditions. Hospitals are finding new ways to reposition critically ill patients through microshifts to keep all patients moving.
• Over half of these patients are unable to shift without assistance
• Over a quarter had a condition that prohibited repositioning
 The system helped identify that over a quarter of patients refused repositioning despite its
importance. Hospitals are working with patients and families to better understand their reasons
for refusal and develop solutions to keep their skin safe.
 Device-related pressure ulcers continue to be an opportunity for improvement as more than 40
percent of serious pressure ulcers were device-related.
• All team members, including respiratory and ear nose and throat surgeons, are
committed to keeping patients safe and are becoming involved in pressure ulcer
prevention.
Falls (pg. 19)
Falls are a continuing concern not only for hospitals but for the home, long term care, in the
community and other settings. Hospitals continue to work to prevent patient falls.
 With knowledge gained from the reporting system, hospitals have been able to identify a risk for
serious injury for patients on anticoagulant medications if they do fall.
 The majority of patients who died from their fall injury were on anticoagulant medications (to
prevent blood clotting) and suffered a head injury after hitting their head. The majority of these
falls were unwitnessed and the patient denied hitting their head.
 An anticoagulant work group identified best practices specifically for these at-risk patients and
hospitals are working to implement those practices, including:
o Because the risk for serious internal head injury is so great when on anticoagulant
medications, if the fall is unwitnessed staff should assume the patient hit his/her head
and immediately initiate the Rapid Response Team (a team of clinicians with critical care
expertise trained to quickly respond, assess and intervene) and increase the level of
post-fall monitoring for the patient.
 Although falls are an area of concern in the hospital setting, the majority of serious injuries and
deaths from falls occur in the community and at home. MHA is collaborating with long-term
care, clinics, the community and others to keep older adults active and safe across all settings.
 The reporting system identified that many falls occur in and around the bathroom. In 2014,
MHA partnered with MDH, Michael Graves Design and Pope Architects to look at new ways to
design bathrooms to prevent falls, including things such as placement of grab bars, contrasting
colors in floors, walls and toilet seats, placement of lighting on pathways to the bathroom, and
toilet height. These recommendations are being shared with hospitals across the state.
Invasive procedures (pg. 12)
The long-term trend for invasive procedure events is down. Invasive procedures include procedures in
the operating room, radiology, ambulatory surgery, diagnostic/labs and other settings. Given the
volume of invasive procedures performed in Minnesota hospitals, these events are very rare.
Wrong body part/wrong procedures
 Hospitals have seen a decline in the number of events in the operating room with an increase in
the number of events occurring in radiology.
Updated 2/20/15
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 This is due both to an increase in awareness of safe procedure processes and identifying new
opportunity for improvement in radiology, and an increase in the number of invasive procedures
performed in interventional radiology.
 The majority of cases in the operating room were wrong spine level surgeries. This is an area
that continues to challenge health care providers both locally and nationally. This is a highly
specialized and complex process, as the spine is not able to be adequately visualized prior to
incision even with imaging technology.
o As another example of Minnesota being a national leader, MHA is working with leading
spine surgeons to develop and pilot alternate methods of spine localization to reduce
wrong spine level surgeries.
Retained foreign objects (pg. 15)
 As hospitals are experiencing success with preventing retained sponges, instruments and
needles, the Adverse Health Event reporting system has helped hospitals identify an opportunity
to improve practices to prevent the retention of small miscellaneous items and unretrieved
device fragments. These include intact by separated parts of surgical items, broken pieces of
instruments, trocars, guide wires and sheaths.
 With the rise in minimally invasive procedures there has been an increase in the number of new
devices and instruments used in operations and procedures. This creates an increase in the
number and kind of devices used that can possibly break.
o When new devices are introduced, hospitals provide training and education to
familiarize staff with the device so it can be identified if a piece is broken or missing
during a procedure.
o One area we are going to explore is working with device manufacturers to see if
instruments can be redesigned or improved to make them less likely to break.
Suicide/attempted suicide (pg. 21)
In recent years, Minnesota’s overall suicide rate has been rising. While extremely rare, averaging just
three events per year in the past decade, people do attempt to take their life while in the hospital.
 For more than six years, Suicide Awareness Voices of Education (SAVE) has trained
administrators, nurses, physicians and other team members on risk assessment for suicide in
health care settings, including environmental safety issues and staffing best practices.
 Hospitals are working to create a more supportive and understanding environment for patients
who are in a mental health crisis.
o Many behavioral health units are creating sensory rooms that offer quiet places for
patients to relax and calm themselves, helping to prevent a crisis from occurring or
escalating to a suicide attempt.
 Hospitals have looked at how physical spaces can be redesigned to better prevent suicide
attempts by patients, including looking at doors, bathrooms and windows that could possibly aid
a suicide attempt.
 The hospital community is also supporting legislation this year that would provide additional
resources to mental health, including providing more services in the community before a mental
health episode escalates to a crisis in the hospital and better integrating mental health services
with primary care.
 The Minnesota Hospital Association and its member hospitals participated on the statewide task
force to implement a national suicide prevention plan which led to the creation of the Minnesota
Department of Health’s draft 2015 Statewide Suicide Prevention Plan. The plan includes a goal to
promote suicide prevention as a core component of health care services.
Updated 2/20/15
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New events (pg. 25)
Four new events were added to the Adverse Health Event reporting system in 2014. The AHE
reporting system is a living learning system with new measures that get added based upon national
and local learnings.
 This reporting and learning system is a proven way to identify and learn from these events, and
hospitals look forward to gaining a deeper understanding of the factors that contribute to these
events and working collaboratively to put processes and systems in place to prevent future
occurrences across our state.
Five events occurred as a result of failure to follow up or communicate test results (pg. 25).
 A work group of experts is convening to review findings from reported events in this category
and develop strategies to address identified gaps. Recommendations from this expert group,
along with implementation tools, will be disseminated to hospitals and ASCs across the state.
Twenty events related to the irretrievable loss of an irreplaceable biological specimen (pg. 25-26).
 In late 2014, an expert group was convened to review findings from reported events and
develop recommendations to address key improvement opportunities. Work is also underway
to combine these practices with other surgical safety practices to create a comprehensive set of
recommendations across the topics of: correct site procedures, correct procedure, correct
patient, prevention of retained foreign objects, and safe specimen handling.
There were six deaths or serious injury of a newborn associated with labor and delivery in a low risk
pregnancy (pg. 26-27).
 This is a tragic event and we are deeply sorry it occurred. The health and safety of hospitals’
smallest patients is of the utmost importance.
 Tracking these events is a nation leading example of Minnesota hospital leadership in
continuously improving patient safety. This particular event is an important new addition to this
reporting system this year and hospitals are working together to learn from these events to
strengthen their processes and prevent future events.
 A low risk pregnancy can turn into a high risk birth in a moment at any hospital.
 Hospitals practice for these emergent situations through simulations. Practicing for these
situations gives hospitals the best opportunity to respond quickly, efficiently and reliably to
whatever emergency is going on.
For more in-depth messaging related to neonate events, see the MHA Member Center.
There were zero events reported under death or serious injury of a patient associated with the
introduction of a metallic object into the MRI area (pg. 27).
 Hospitals have been working on this area for a number of years and have strong policies and
procedures in place following a safety alert from The Joint Commission in 2002.
Workplace violence prevention
Hospitals are committed to providing the highest quality, safest care possible to patients, and that
includes ensuring a safe environment for staff.
Hospitals are committed to building a culture in which violence in health care settings is not
considered part of daily life for health care professionals.
Updated 2/20/15
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 In 2014, hospitals were part of a broad coalition of health care stakeholders who developed a
set of comprehensive best practices and tool kit for hospitals to effectively prevent and respond
to workplace violence toward staff.
 The coalition’s work resulted in a road map for health care organizations to help identify risks
for violence and put effective strategies in place, including the formation of an interdisciplinary
workplace violence prevention committee and conducting in training and education.
 To date, 66 hospitals have formally signed on to participate in the Prevention of Violence in
Healthcare effort.
Updated 2/20/15